pei xis handbook

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INFORMATIONHANDBOOKON

ANAPHYLACTIC SHOCK

Second Edition

_________

PRINCE EDWARD ISLAND

DEPARTMENT OF EDUCATION

AND

DEPARTMENT OF HEALTH

AND SOCIAL SERVICES

JULY 1997

The information presented herein has been adapted from publications of the Allergy/

Asthma Information Association, Canadian Society of Allergy and Clinical Immunology

and from other sources. Additional information may be obtained from the Allergy/Asthma

Information Association, 30 Eglington Ave. N., Suite 750, Mississauga, Ontario L5R 3E7

or the Allergy/Asthma Information Association Atlantic, 20 South Road, Doaktown, N.B.

E0C lG0 (506-365-4501).

The P.E.I. Chapter of the Allergy/Asthma Information Association provides resources

and information sessions for parents and school staff. The telephone contact for the

Chapter is 569-3507.

Reference should be made to Ministers Directive, Procedures for Dealing with Life-

Threatening Allergies.


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TABLE OF CONTENTS

I. Introduction

II. Definition of Anaphylactic Shock

III. Symptoms of Anaphylactic Shock

IV. Prevention and Management Procedures

A. Prevention

B. EpiPen (epinephrine)

C. Emergency Action

V. Responsibilities

A. School BoardsB. Parents

C. Public Health Nurse

D. Principal

E. Department of Education

VI. Extreme Allergy Management and Prevention Plan

VII. Emergency Allergy Alert Form

VIII. School Lunch Ideas

IX. Consultation with Parents

Appendix 1 - Letter to Parents Concerning Anaphylactic Shock Program

Appendix 2 - Extreme Allergy Management and Prevention Plan

Appendix 3 - Emergency Allergy Alert Form

Appendix 4 - School Lunch Ideas

Appendix 5 - Letter to Parents of Students in Attendance at the School

Appendix 6 - Letter Concerning Annual Review of Extreme Allergy Management

and Prevention Plan

Appendix 7 - Order for Additional EpiPens


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1

I. INTRODUCTION

As many as one percent of Canadians suffer from an extreme life-threatening allergy to certain

foods, medications, or insect stings. For them, exposure to even a minute amount (1/5000 th of a

teaspoon) of the substance to which they are allergic can trigger anaphylactic shock.

Anaphylactic shock is an allergic reaction in all the major body-organ systems. Immediate

medical intervention is necessary as the victim may suffer a drop in blood pressure, loss of

consciousness and death. This can occur at any time up to four hours following exposure to the

triggering substance. Even a small amount of the allergen can be fatal.

Although peanuts and peanut products are the most common foods that cause anaphylactic shock,

shellfish, fish, eggs, sulphites, milk, or any other food can cause this dangerous condition in

allergic individuals. Each subsequent exposure to the allergen can increase the severity of

the reaction.

The emergency response to this condition is the administration of epinephrine by syringe, usuallywith an EpiPen . Epinephrine can be safely administered with these devices by non-medical

personnel with minimal training.

The information provided in this Handbook is intended to assist school personnel with strategies

for the management of students who have had anaphylactic shock in the past and are at risk of

anaphylactic shock.

II. DEFINITION OF ANAPHYLACTIC SHOCK

Anaphylactic shock is an allergic reaction which may be fatal, and it occurs when an allergic

individual is exposed to a particular material such as peanut products, nuts, eggs, fish, or is stungby an insect such as a bee, hornet or wasp, or is given medication such as penicillin or aspirin.

III. SYMPTOMS OF ANAPHYLACTIC SHOCK

In the case of a student who has had anaphylactic shock previously and who is exposed to a

particular material, the occurrence of any of the following symptoms, in any combination, indicate

anaphylactic shock:

C hives and itchiness on any part of the body;

C swelling of any body parts, especially eyelids, lips, face or tongue;

C nausea, vomiting or diarrhea;C coughing, wheezing or change of voice;

C difficulty breathing or swallowing;

C throat tightness or closing;

C panic or sense of doom;

C fainting or loss of consciousness.

Immediate administration of the EpiPen (epinephrine)isrequired in the instance where a student


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who has had anaphylactic shock previously exhibits any of the above symptoms following

exposure to a particular material.

IV. PREVENTION AND MANAGEMENT PROCEDURES

When a student who is subject to extreme allergic reactions is identified by the parent, the

principal will coordinate the development of procedures to enhance the safety of the

student. The following elements will be addressed in the plan.

A. Prevention

A prevention plan to minimize the students exposure to the triggering material, appropriate to the

maturity and reliability of the student and the severity of the problem, should be developed.

Prevention measures may include:

C self-supervision;

C education programs for classmates, schoolmates, parents;

C request to parents of students in classroom to assist in management of exposure

to the allergen; andC minimizing the presence of triggering material in school and school-related

activities.

The Allergy/Asthma Information Association and the Canadian Society of Allergy and Clinical

Immunology recommend that allergies to peanuts and peanut products require more stringent

management plans. Reactions to peanuts are generally more severe than reactions to other foods.

Therefore, strong initiatives to control exposure to peanut products are warranted.

Younger students are obviously more dependent and require a higher level of care. At the

elementary school level, avoidance policies are highly desirable. In any school where a student

who is at risk of anaphylactic shock is enrolled, the objective should be the establishment of aclassroom or classrooms which are free of the substance which could place the allergic student at

risk of anaphylactic shock. All parents of students enrolled in the class should be provided with

information and informed that a student in the classroom is at risk of anaphylactic shock. Parents

should be asked to exclude the particular food products or substances from lunches and snacks.

At the secondary level, the implementation of avoidance policies, although desirable, may be more

difficult. However, efforts should be made to limit exposure to the risks.

In a school where a student who is at risk of anaphylactic shock is in attendance, school personnel

should plan to control activities which increase risk. Students should be discouraged from eating

lunches or snacks on playgrounds, in corridors, or in other facilities shared by students. Students

should also be discouraged from sharing lunches. The use of food in art classes and homeeconomics classes may have to be restricted. Parents who send treats to school for particular

occasions should be asked to exercise caution. Suppliers of cafeteria services should be informed

about the presence of a student who is at risk of anaphylactic shock and asked to institute

avoidance policies.

B. EpiPen (epinephrine)

EpiPens (epinephrine) supplied by parents or the Department of Education must be available,


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and all staff who may be required to administer the medication must be trained to do so. A

mechanism by which all staff can identify the students at risk should be available. Provision

should be made for informing substitute teachers and other temporary staff about the student and

their potential responsibilities. The number of locations at which EpiPens (epinephrine) are kept

should be determined based upon the severity of the problem as mutually determined by the

parent, principal and public health nurse. The preferred approach would be for the student to

carry the EpiPen (epinephrine) at all times. The regular EpiPen (epinephrine) is used for

persons over 33 pounds.

In situations where it is uncertain that anaphylactic shock is occurring, it is advisable to

administer the EpiPen (epinephrine). There is very little chance of reaction to the

medication and any reaction is usually very mild, but there can be serious consequences if

an anaphylactic reaction is occurring, and the EpiPen (epinephrine) is not given.

C. Emergency Action

As in the case of any potential crisis, advance planning will be helpful in successfully managing the

event. In dealing with cases of anaphylactic shock, the emergency action is as follows:

C Get EpiPen (epinephrine) and administer immediately.

C HAVE SOMEONE CALL AN AMBULANCE and advise of need for an

EpiPen (epinephrine).

C Unless student is resisting, lay student down, tilt head back and elevate legs.

C Cover and reassure student.

C Record the time at which EpiPen (epinephrine) was administered.

C Have someone call the parent.

C If the ambulance has not arrived in 10-15 minutes, and breathing difficulties are

present, administer a second EpiPen (epinephrine).

C Even if symptoms subside, take student to hospital immediately.

C If possible, have a school staff member accompany the student to the hospital.

C Provide ambulance and/or hospital personnel with a copy of the Extreme Allergy

Management and Prevention Plan for the student and the time at which the

EpiPen (epinephrine) was administered.

In the case of a student who has had anaphylactic shock previously, particular attention has to be

given to the management of field trips and other school activities off the school property. School

personnel should ensure that the required emergency plan can be implemented if the need arises.

School personnel should seek the advice and assistance of parents on these matters.

The implementation of prevention plans reduces, but does not eliminate risks. Even with the

adoption of avoidance policies, it is unwise to assume that a school is free of a particular allergen.

V. RESPONSIBILITIES

The School ActR.S.P.E.I. 1988, Cap. S-2.1, includes specific provisions with regard to the

responsibilities of teachers and school staff where a student is injured or there is a medical

emergency. The provisions are contained in section 117 of the Act:


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117. (1) Where a student is injured or there is a medical emergency, teachers and school staff

shall provide assistance to the student and obtain medical treatment where necessary.

(2) Costs of medical treatment, including ambulances, shall be borne by the student or theparent. 1993, c.35, s.117.

In the absence of parental authorization, school staff have a legal obligation to administer the

EpiPen (epinephrine) and follow the emergency procedures when there is reasonable grounds to

assume that the student is having an anaphylactic reaction.

The management of students who have severe allergies requires a clear understanding of the roles

of the parent and school and health personnel. These responsibilities are described in the

following sections.

A. School Boards

The identification of students who are at risk of anaphylactic shock can be accomplished by

including questions in the student registration form. School boards are required to include the

following questions in the form:

(a) Does your child have a life-threatening allergy to certain

foods, insect venom, medication or other material? YES NO

(b) If your answer to the above question was yes,

(i) Please indicate the substance to which

your child is allergic. ________________________________________

(ii) Has a medical doctor recommended that your

child have an emergency medical kit (EpiPen )

available for use at school? YES

NO

B. Parents

Parents are required to assume a number of responsibilities. It is important that parents providecertain information to the principal at the time that the student is registered to attend school.

Necessary forms and authorizations should be completed. In addition, parents may be required to

delay their students attendance at school until the necessary management plans are established.

Parents have specific responsibilities for providing

C the school principal with information about the students allergy;

C assistance to the principal by having the students medical doctor complete


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the Allergy Information section of the Extreme Allergy Management and

Prevention Plan and by providing authorization and consent to carry out

emergency procedures;

C a completed copy of the relevant sections of the Emergency Allergy Alert

Form;

C a recent photo of the student;

C the student with a Medic Alert bracelet or other suitable identification;

C the student with a carrying pouch and an unexpired EpiPen (epinephrine)

which will be available for use at school, during field trips and on the bus.

C. Public Health Nurse

Proper planning for the management of students with severe allergies requires support from health

care workers. Public health nurses are responsible for a number of support activities.

The specific responsibilities of the public health nurse are to

C assist with the identification of students who have life-threatening allergies;

C conduct education programs for parents and school staffs;

C conduct training for school staff who may be required to administer the EpiPen

(epinephrine);

Cassist the school principal and the parent with the development of the ExtremeAllergy Management and Prevention Plan for each identified student.

D. Principal

The principal is responsible for planning and coordination with regard to the management of

students who have life-threatening allergies. Upon being informed by the parent and/or through

the student registration form that a student is at risk of anaphylactic shock, the principal shall

C provide, or forward to the parent, copies of Ministers Directive, No. MD 97-06,

Procedures for Dealing with Life-Threatening Allergies, the Extreme Allergy

Management and Prevention Plan, and the Emergency Allergy Alert Form;

C provide an opportunity for the parent to attend a meeting with school personnel

for the purpose of completing and/or reviewing the Extreme Allergy Management and

Prevention Plan and the Emergency Allergy Alert Form when the student registers to

attend the school and annually thereafter;

C provide information about the student and the students allergies to the school staff,

cafeteria staff, bus driver and substitute personnel who may be required to assess the


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E. Department of Education

The Department of Education shall

(a) provide additional EpiPens (epinephrine) to schools for use in an emergency

according to the following formula:

Number of students registered No. of EpiPens

at the school who are at risk to be provided

of anaphylactic shock to schools

1 student 2 EpiPens

2 - 4 students 4 EpiPens

5 or more students 6 EpiPens

(b) maintain records concerning the distribution of EpiPens (epinephrine) to

schools and notify principals at least one month in advance of expiry dates of

EpiPens (epinephrine) supplied to schools by the Department of Education.

EpiPens (epinephrine) obtained from the Department of Education are to be stored in an

accessible location at the school for use in an emergency. In the case of field trips, the teacher in

charge of the trip should take an EpiPen (epinephrine) from the supply at the school even if the

student is carrying an EpiPen (epinephrine). The Department will not, given the problems with

storage, provide EpiPens (epinephrine) for placement on school buses. The parent is expected to

provide their child with one unexpired EpiPen (epinephrine) which will be available for use at

school, during field trips and on the bus. The Order for Additional Epipens is contained in

Appendix 7.

VI. EXTREME ALLERGY MANAGEMENT AND PREVENTION PLAN

A copy of a letter to parents concerning the Anaphylactic Shock Program is contained inAppendix 1. This letter should be forwarded to those parents who have indicated that their child

is at risk of anaphylactic shock. A copy of the Extreme Allergy Management and Prevention Plan

and a copy of the current Ministers Directive concerning Procedures for Dealing with Life-

Threatening Allergies should be included with the letter.

The Extreme Allergy Management and Prevention Plan should be completed for each student who

is at risk of anaphylactic shock. The Plan requires the provision of information from the parent

and the students medical doctor. It also provides for the documentation of commitments by the

public health nurse, the school and parent. Finally, the Plan requires the parent to give


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authorization for the public health nurse and the school staff to administer medication and obtain

medical assistance. A completed copy of the Plan should be provided to the students teacher(s),

substitutes, bus driver and other staff who deal with the student. A copy of the Extreme Allergy

Management and Prevention Plan is included in Appendix 2.

Parents are required to return a completed copy of page 1 of the Extreme Allergy Management

and Prevention Plan within 15 days. If a parent does not respond within 15 days and the principal hasinformation that the child is at risk of anaphylactic shock, the principal is required to notifystaff who deal with the student, arrange for the public health nurse to conduct an information andtraining session for staff and order the required number of EpiPens (epinephrine) from the

Department of Education.

Parents whose children are at risk of anaphylactic shock should be provided with the opportunity

to have the plan for their child reviewed at the beginning of each school year. A letter to parents

concerning the annual review of the Extreme Allergy Management and Prevention Plan is

contained in Appendix 6.

VII. EMERGENCY ALLERGY ALERT FORM

The Emergency Allergy Alert Form is a short version of the management plan and is designed for

posting within the school so that information is readily available in an emergency. The Emergency

Allergy Alert Form is to be completed by the parent and the principal. The Form includes

sections for recording information about the students allergy. The Form also contains a

description of the symptoms of anaphylactic shock and the action which is appropriate in an

emergency. A photo of the student, if supplied by the parent, should be attached to the Form. A

completed copy of the Emergency Allergy Alert Form should be posted in the staffroom, school

office or other appropriate location within the school. An EpiPen (epinephrine) should be

located with the Form. A completed copy of the Emergency Allergy Alert Form should be

provided to the students teacher(s), substitutes, bus driver and other staff who deal with the

student. A copy of the Emergency Allergy Alert Form is included in Appendix 3.

In instances where parents do not complete the Form or give permission, posting of the Form will

not be possible.

VIII. SCHOOL LUNCH IDEAS

Appendix 4, School Lunch Ideas, contains suggestions for school lunches which do not include

peanut butter. It will be necessary to develop a different list of ideas in cases where a student isallergic to any of the foods included in the list. In these instances, consultation with a nutritionist

is desirable. This information could be provided to parents through school newsletters, at parent

meetings, or attached to correspondence to parents concerning the presence of a child who is at

risk of anaphylactic shock.


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IX. CONSULTATION WITH PARENTS

The creation of classroom spaces and buses which are free from the substance which could place

an allergic student at risk of anaphylactic shock is more likely to be achieved through the use of a

consultative process. Efforts should be made to provide parents with information about the risks.

A sample letter to parents is included in Appendix 5. This letter is designed to inform parents

about the presence of a student who is at risk of anaphylactic shock following exposure topeanuts and peanut products. The letter can be modified for cases where students are at risk of

anaphylactic shock following exposure to other substances. An invitation to a school meeting is

included in the sample letter. Of course, the letter should be adapted to meet the particular

circumstances.


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APPENDIX 1

Letter to Parents ConcerningAnaphylactic Shock Program


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Students Name ______________________ Parents Name ______________________

Dear Parent:

RE: ANAPHYLACTIC SHO CK PROGRAM

The Department of Education has established a program for the management of students who are

at risk of anaphylactic shock. The following are attached for your consideration: (1) Ministers

Directive, Procedures for Dealing with Life-Threatening Allergies, (2) Extreme Allergy

Management and Prevention Plan, and (3) Emergency Allergy Alert Form.

Anaphylactic shock is an allergic reaction which may be fatal, and it occurs when an allergic

individual is exposed to a particular material such as peanut products, nuts, eggs, fish, or is stung

by an insect such as a bee, hornet or wasp, or is given medication such as penicillin or aspirin.

If a doctor has advised that your child may require epinephrine, adrenaline, or an EpiPen for an

anaphylactic reaction, you and your doctor are asked to complete only page 1 of the enclosed

form entitled EXTREME ALLERGY MANAGEMENT AND PREVENTION PLAN and

return it to the school. A meeting will be arranged with you if necessary, and pages 2 and 3 will

be completed at that time. Please review the Ministers Directive, Procedures for Dealing with

Life-Threatening Allergies, and give particular attention to responsibilities of parents.

It is important that a plan is established as soon as possible for those children who are at

risk of anaphylactic shock. If you do not respond within 15 days, it will be assumed that

your child is not at risk of anaphylactic shock, and that a management plan is not requiredfor your child.

Thank you for your cooperation.

__________________________

Principal

Please detach and return to your childs teacher.

-------------------------------------------------------------------------------------------------------------------------

Students Name ____________________________________________

This student is not at risk of anaphylactic shock and does not require a management plan.

___________________________ __________________________________________________

Date Parents Signature


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APPENDIX 2

Extreme Allergy Management and Prevention Plan


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EXTREME ALLERGY MANAGEMENT

AND PREVENTION PLAN

Page 1 of 3

School ________________________ Home Room Teacher _________________

Student Information (To be completed by Parent)

Students Name___________________________ Date of Birth _______________

Medic Alert I.D. _____________Health Card Number (Optional)______________

Parents Name ______________________________________________________

Address ______________________________________________________

______________________________________________________

Telephone - Home ________________Work _______________________

Name of Emergency Contact Person _______________________________________

Telephone - Home ________________Work _______________________

Name of Family Doctor ___________________ Telephone _________________

Allergy Information(To be completed by Students Medical Doctor)

Anaphylactic shock is an allergic reaction which may be fatal, and it occurs when an

allergic individual is exposed to a particular material such as peanut products, nuts,

eggs, fish, or is stung by an insect such as a bee, hornet or wasp, or is given

medication such as penicillin or aspirin.

History of Anaphylactic Reaction? Yes No

If yes, to what? _________________________________________

Any other significant allergies? Yes No

If yes, describe _________________________________________

_________________________________________

EpiPen (epinephrine) recommended? Yes No

If yes, Junior (under 33 lbs.) Regular (33 lbs. or over)

Department of Education policy requires that all students at risk of anaphylactic

shock carry an unexpired EpiPen (epinephrine) which will be available for use at

school, during field trips and on the bus.

Date_______________ Medical Doctors Signature ______________________


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AND PREVENTION PLAN

Page 2 of 3

Students Name _________________________________________________

(The completion of the following sections is to be coordinated by the principal.)

Public Health Nurse Commitments: _________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

School Commitments: ___________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Parent Commitments:_______________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________

Date _______________ Principals Signature ___________________________

Date _______________ Public Health Nurses Signature _________________


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AND PREVENTION PLAN

Page 3 of 3

Students Name _________________________________________________

PARENT AGREEMENT

I, _______________________, acknowledge and understand my participation in the development of

the preceding Extreme Allergy Management and Prevention Plan and the Emergency Allergy Alert

Form, and I agree to execute reliably the parent commitments. I hereby request and give my consent

for staff or personnel of ________________ School and the public health nurse to execute the

commitments as outlined within the plan.

In the event of an emergency, I authorize the school staff to administer the designated medication and

obtain suitable medical assistance. I agree to assume responsibility for all costs associated with

medical treatment, and I release the School Board, its employees, agents, volunteers and public health

nurses, from any liability for loss, damage or injury, howsoever caused, to my childs person or

property arising out of the administration of the procedure as provided herein.

I agree that this information will be shared, as necessary, with the staff of the school and health care

systems.

Date _________________ Parents Signature __________________________________

_______________________________

This Plan is to be reviewed annually and revised, where appropriate.

Copy to: Parent Teacher(s) including specialists Public Health Nurse

Principal Bus Driver Custodian

School Secretary Substitutes Other staff who deal with

the student.


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APPENDIX 3

Emergency Allergy Alert Form


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APPENDIX 4

School Lunch Ideas


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SCHOOL LUNCH IDEAS

Although no food is universally safe for all food allergic individuals, the following are some interesting suggestions alternatives to peanut butter sandwiches.

Sandwich Fillings:

C chicken - sliced, smoked or chicken salad;C

turkey - sliced, smoked or turkey salad;C lean beef or ham - minced or sliced;C pork - sliced or chopped, try adding applesauce or relish;C lean luncheon or deli meats;C cheese spread, or molasses;C sliced cheddar with jam or mayonnaise;C processed cheese with sliced apple, pickles, or crumbled bacon;C cream cheese with chopped maraschino cherries or chopped olives;C sliced meat loaf.

Tired of plain bread? Try:

C whole wheat, oatmeal, rye, or pumpernickel;C

pita pockets or english muffins;C bagels, hot dogs or hamburg buns, soft tortilla shells;C hard rolls, sub buns, biscuits, croissants, crackers or rice cakes.

Ideas for wide-mouth hot thermos:

C spaghetti, macaroni, other pasta or rice dishes;C soups, stews, and casseroles;C chicken nuggets, or leftovers.

Try these in a wide-mouth cold thermos:

C potato salad or pasta salad with cubes of cheese or meat;C

chef salad or vegetable salad with a separate dish of dressing;C fruit salad with cottage cheese;C cubes of meat or cheese to accompany crackers, carrot and celery sticks

and a small container of dip.

Miscellaneous other favorites:

C pizza;C whole grain muffins with yogurt or cheese;C cooked wiener, split and stuffed with cheese;C whole grain cold cereal - bring in separate covered bowl and add milk from a thermos

or the school milk program.

To make sure a lunch is nutritionally balanced, enjoy a variety of foods from the four food groups in Canadas FoodGuide to Healthy Eating. To keep packed lunches cool, chill as much as possible overnight or try packing a smalllunch-size ice pack in the lunch box or insulated lunch bag. Some items can even be packed frozen and will thaw intime to be eaten.

Compiled by Jackie Hamm, Allergy/Asthma Information AssociationNutritional Assistance by Jackie Vloet-Koughan, DieticianDepartment of Health & Social Services


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APPENDIX 5

Letter to Parents of Studentsin Attendance at the School


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Dear Parent:

A student who is registered at our school has a severe life-threatening allergy to peanuts and peanutproducts. Exposure to even a minute amount of the food substance could cause anaphylactic shock and,without immediate emergency medical assistance, loss of consciousness and death. The school hasestablished an emergency plan for the student.

The school has an obligation to establish a safe environment for all students. Therefore, we are requestingthat parents avoid including peanuts and peanut products in lunches or snacks. Information concerningSchool Lunch Ideas is attached; a number of alternatives to peanut butter sandwiches are suggested.

Our objectives are to establish and maintain, to the extent possible,

C classrooms, attended by the student, which are free of the substance which could place the

student at risk of anaphylactic shock;

C school practices which reduce the possibility of exposure to substances which causeanaphylactic shock; and

C buses which are free of substances which could place an allergic student at risk of anaphylashock.

A meeting for parents has been scheduled for _____________ at the school. The purposes of the meetinare to share information concerning anaphylactic shock and to seek cooperation from parents in order toreduce the risk of exposure to peanuts and peanut products. If you are unable to attend, please telephoneschool for additional information.

Thank you for your assistance with this important matter.

Sincerely,

Principal

Attachment


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APPENDIX 6

Letter Concerning Annual Review ofExtreme Allergy Management and Prevention Plan


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Dear Parent:

Department of Education policy concerning the management of students who have a life-threatening allerg

and who are at risk of anaphylactic shock includes a provision for an annual review of the management pl

The Extreme Allergy Management and Prevention Plan for ___________________ wasstudents name

completed and/or reviewed in _____________________.month/year

Please complete the attached survey and forward it to your childs teacher.

It is important that the review of the plan for your child is completed as soon as possible. If you donot respond within 15 days, it will be assumed that changes to the Extreme Allergy Management aPrevention Plan are not required.

Principal

Please detach and return to your childs teacher.--------------------------------------------------------------------------------------------------------------------

Students Name ________________________________________________________________

The Extreme Allergy Management and Prevention Plan for my child

does not require any changes. or

I wish to have the Extreme Allergy Management and Prevention Plan

for my child reviewed, and I request a meeting with school personnel.

___________________________ ________________________________________________Date Parents Signature


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APPENDIX 7

Order for AdditionalEpiPens


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Department of Education

Order for Additional EpiPens

The form is to be used to order the initial supply ofEpiPens and to order replacements for expired or used EpiPens , or in instanc

where new students register at the school.

Parents of a student who has a life-threatening allergy shall be responsible for providing the student with a carrying pouch and anunexpired EpiPen (epinephrine) which will be available for use at school, during field trips and on the bus.

The Department of Education will supply additional EpiPens to schools according to the following formula:

Number of students registered No. ofEpiPens

at the school who are at risk to be providedof anaphylactic shock to schools

1 student 2 EpiPens

2 - 4 students 4 EpiPens

5 or more students 6 EpiPens

School _________________________________________________________________________

Names of students who are at risk Has the Extreme Allergy Management and Prevention Plan

of anaphylactic shock. been completed by parent and medical doctor?

__________________________________________ 9 YES 9 NO

__________________________________________ 9 YES 9 NO

__________________________________________ 9 YES 9 NO

__________________________________________ 9 YES 9 NO

__________________________________________ 9 YES 9 NO

__________________________________________ 9 YES 9 NO

__________________________________________ 9 YES 9 NO

__________________________________________ 9 YES 9 NO

__________________________________________ 9 YES 9 NO

Number of unexpired EpiPens in Junior (under 33 lbs) ________________

school inventory from previous order: Regular (33 lbs or over) ________________

Expiry date(s) for EpiPens in

school inventory: ____________________________________

Number of new EpiPens required : Junior (under 33 lbs) ________________

Regular (33 lbs or over) ________________

____________________________ _________________________________________

Date Principal

Please forward to :

Policy and Evaluation Division

Department of Education

P.O. Box 2000, Charlottetown, PE ClA 7N8

FOR OFFICE USE

Number ofEpiPens shipped to school: Junior __________ Regular __________

Expiry Date

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